Medicine in London, 1600 to 1900 - A well-scrubbed world

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MEDICINE IN LONDON 1600-1900

A WELL-SCRUBBED WORLD

Dr Allan Chapman

Tonight, I have got a very wide area I want to deal with, and this is because there is simply more that happened in the 19th Century than in any previous century in the history of medicine. The people who were at my previous lectures should remember that I have mentioned things like critical masses of medical information; that you need medicine and medical innovation to get to a certain critical mass before you had a proper bridging point between, on the one hand, the research, and actual practical therapies that could be applied. In the latter part of my lecture tonight I want to look at that critical mass - where it came from, what it constituted, and how it started to what you might call fire a large engine, which was not only physiologically and intellectually fascinating but therapeutically valuable at the same time. This, of course, is the ancient practice of medicine: the idea of an intellectual understanding of the body that also had practical applications. But not until more or less after about 1850 does this really take place in any big scale.

I finished my lecture last week by mentioning a poem, one of the body-snatching poems called 'Mary's Ghost', which concluded, 'Although you will always have my love, Sir Astley has my heart.' I want to start by saying who Sir Astley is, because he is one of the great bridge points into 19thCentury surgery. He was born in 1768 in Norfolk and he died in London in 1840 - he is Astley Paston Cooper, Baronet.

In 1800 Cooper was 32 years old, and he was one of the tyros of British surgery. He was a figure who was leading the way, one of the great, great dissectors. He simply has to fight off his students because he has more pupils than he can manage, and of course he acquires his surgeonship at what was then called the United Hospitals of Guy's & St Thomas'. He became the greatest surgical teacher of probably the first twenty years, if not thirty years, of the 19th Century.

One has to ask what actually could a surgeon do in 1830 which they could not do in 1660, bearing in mind of course you still could not control pain, you could not control infection and you could not control surgical trauma at all. Quite simply, by 1830, the knowledge of the deep anatomical structures of the body, at least those parts of the body that you could risk operating on - legs, arms, extremities, bladders, etc. - all of these things were known in great detail, in-depth, all the way through.

It therefore becomes possible if, for example, you have to amputate a gangrenous leg, then you could then decide the exact point on which to amputate. You know exactly how many blood vessels you are going to have to ligature, exactly where to apply a hoped-for if not anaesthetic, pain-numbing device, a clamp with which you could grip the nerve for about three or four hours in advance so that the leg went as dead as it could go. You could therefore decide exactly how to perform the operation. You could prepare your instruments in advance, and you would have an assistant or a dresser with a stop watch, and you would take record of how fast you could go. Of course you still, like I say, have no control of pain, but in many ways you could say you could control or limit pain by the very fact that you could then do operations in record time. Whereas a surgeon in the days of Harvey would have taken anything up to ten minutes perhaps to remove a leg, and of course they would have culminated it with usually using hot irons to cauterise. But by 1830, Cooper could remove a leg at the knee in under two minutes flat. He would have, we are told, beforehand, a series of threaded silk needles in the lapel of his waistcoat. Of course they wore an old coat for operating so the blood did not spoil your fine clothes. He would know how many vessels he would have to ligature. He would plan the exact size and extent of the flap that he was going to require to close the wound. Then, when he got going, quite literally, he would know exactly what he had to do, each of his dressers would have been told exactly what they had to do to staunch the blood and seal up the wound within two minutes.

This tradition got faster and faster, right until 1846, when Robert Listen, a Scottish surgeon who had taken up his career at University College London, actually performed the very first operation using an anaesthetic - sulphuric ether - on the 21st of December 1846. I want to come back to post-anaesthetic surgery later on in the lecture, but I wanted to begin with this point to show basically that if there was one branch of the healing arts that was genuinely making rapid progress in this time, it was broadly amputative surgery, which could become more predictable and which would have, on the whole, about a 50/50 survival rate. It may not sound very great, but after all, a minute or a two minute operation reduces trauma, and although they did not know it, it reduced the amount of time that you were sticking unwashed fingers and unsanitised instruments into wounds. Therefore, survival rates got a little better, but still you could not touch the major cavities of the body. The abdomen, the thorax and the cranium were still out of bounds. It was known by Astley Cooper, by Listen, by Thomas Cline, by all the great and what they considered as virtuosic surgeons of that age, that simply if you opened those cavities, the person died through infection, no matter how good the techniques of operation.

Also too, what it tends to show is that people were starting to collate data together, and doctors start - not only across England or across London, but across Europe - to exchange medical and surgical data on procedures. And of course you could say, on a slightly mercenary side, this could improve your practice. If it was known for instance that you could remove bladder stones in two minutes, then you would probably get more people who could afford that operation coming to you than somebody who would take ten minutes to do it; similarly for a leg amputation or any other operations, and this is why the timing of operations became so crucial, as a sort of medical marketing ploy.

Now, having said that about Astley Cooper, and of course the messy basis of dissection on which his reputation and his surgical practice was based, I want now to say something about the nature of medicine in London as a structure at that time.

In 1800 London had just topped a population of one million. It was one of the biggest cities in the history of the world and it was, frankly, filthy. It would be even filthier half a century later, when Kingsley made the remark that Southwark, where many people took their drinking water from, also had dead cats, excrement, and ship wreckage floating in that water. Basically speaking, the city needed cleaning up. But before you could actually start cleaning, if you had any concept of the importance of cleanliness, you had to ask what was happening within the structures of hospital care.

Last week, I mentioned that the 18th Century saw effectively five significant teaching hospitals becoming operational in London, or at least five hospitals being founded that developed important teaching functions by the 1780s - the famous walking of the wards.

In contrast, the 19th Century saw a veritable explosion of hospitals. It is true that there were the great hospitals - Guy's, St Thomas's, Bart's, St George's, and so on - but there were also of course two major new academic hospitals that were founded: University College Hospital; and King's College Hospital. King's of course would later become famous as the great centre of antiseptic surgery, after 1877, with Joseph Lister, not of course to be confused with Robert Liston, with whom, rather ironically, he happened to have been a pupil.

What you also start to find is a number of hospitals for specific diseases or population groups, which is a thing which had not really existed in the past, with the exception of the Lock Hospital for venereal cases in Southwark. For instance, 1848 saw the founding of the London Chest Hospital. The purpose of this hospital, primarily, was to monitor and study Phthisis, pulmonary consumption. You basically did this by a number of techniques: auscultation was the principal one. You used early forms of stethoscopes, and tapping of the back and chest to try to determine the level of deterioration of the lungs of individual patients. There were virtually no ways of curing the disease, and anybody who went into the London Chest Hospital with tuberculosis in virtually any form probably would not leave it standing up. But even so, what this starts to do is to create a massive new reservoir for the study of a major disease.

People in the 19th Century were alarmed at the escalation of tuberculosis. It had always been there - tuberculoses material has been found in the preserved lungs of Egyptian mummies - but why did it explode?

People in the 19th Century become beloved of statistics. They started to ask what groups of the population are most likely to suffer from which diseases, what we would now call, socio-economic brackets are they in, where did they live, what did they eat, what did they do for their livings, and so on. From these statistics you start to find the founding of these hospitals primarily to monitor complex diseases within a complex population - by 1850, a million and a half in London.

So you have the Chest Hospital. You have the founding too, in 1843, of the Women's Hospital in Red Lion Square, again the first place to systematically study diseases of women. The forming of the hospital which later became Great Ormond Street, the London Children's Hospital, starts in the 1840s as well; and in 1856, the Fulham Cancer Hospital. There were others as well - for the study of the eyes, for the study of the speech. So all kinds of malfunctions of the body then had some kind of institution to deal with them.

Of course many of these hospitals would be small - they may only have ten or twenty beds - but nonetheless, you are beginning to have a focus on particular diseases, and the emergence, as I will be mentioning in a few minutes, of medical specialism. Therefore, you have this great explosion in the concept of care.

Where was it paid from? - Basically speaking, private charity subscriptions. The Government in the 19th Century did not spend on public medicine, the idea being that this would be coming out of private subscribers. Therefore it carries on the 18th Century tradition of, broadly speaking, Christian charity - money out of private pockets for an increasing burden of disease. This seemed to be particularly acute for London, but it was also shared with Liverpool, Manchester, Cardiff, Newcastle, and the other rapidly growing cities of the age. The biggest diseased groups of the population were the poorest, the dirtiest, and the least nourished, and statistically, people started to ask exactly why is this happening.

I want to speak about the profession; the way in which one had a medical profession emerging in the early part of 19th Century England. We of course have always had the ancient category of 'doctor' - doctor of medicine, bachelor of medicine at Oxford and Cambridge, as of course did the Scottish and the European universities, going back to the 13thCentury, if not before. The key idea is of course that the number of people who could have a valid doctorate degree and practise medicine was of course inevitably going to be a tiny percentage of the total population.

You then of course had the great vortex of quackery, where you also had the emergence of a large number of carers, medical carers, who did not have necessarily the legal title 'doctor', but were coming to be recognised increasingly as licensed permitted practitioners.

I want to say something about these groups and the strands that came together, but before that, I must say something about the nature of specialisation within medicine. Medicine today is utterly based on specialisation in its higher research branches. This is entirely a 19thCentury phenomenon. If you had gone to Richard Mead, Isaac Newton's physician, in London in 1720, you could have gone to him with typhus, gout, blindness, constipation, bad teeth, anything, and he would have tackled it. Similarly of course, if you needed to have bladder stones removed, teeth removed, a broken arm reset or something like that, you could go to, let us say, somebody like Chesledon, the surgeon. Therefore, those who were in within the elite of the profession, either as doctors or as surgeons, regarded themselves, confidently and grandly, as generalists. The reason for this was basically because you shared one relatively vague concept of illness, and that is illness was, if it were a medical condition, then some sort of blockage, so therefore an astute diagnostician would know how to unblock it, whether it was the blocking of your foot that caused gout, the blocking of your head that made you mad, or whatever.

On the other hand, this reverses in the 19th Century, because in the 18thCentury, you did have specialists - the problem is, you did not want to know them socially - these were quacks. You had people like the gentleman I mentioned last week - John Chevalier Taylor, the great oculist. He only cured the blind, and of course very rarely ever succeeded. He had no medical qualifications whatsoever. You also find the lady I mentioned last week who was a spectacularly irregular practitioner as a bone-setter. You have Graham, the electrical therapist. In 18th Century medical practice, when you talk of 'specialist', basically speaking, you mean quack. The 19th Century reverses that situation. The most elite academic healers, by 1860 or 1870, have become specialists, and rather ironically, the quacks have reverted to general status, where their nostrums will cure everything from falling hair to stiff limbs. I think this is a remarkable phenomenon which happens in the conception of medicine. Why of course it happens, quite simply, is the sheer tidal volume of medical discovery, which makes viable specialism possible in particular conditions, or at least collections of conditions, by the early years of Queen Victoria's reign. So this idea of specialisation grows rapidly, and of course it is the bedrock of modern scientific medicine today.

Then one has to ask what were the organisations which would allow you to call yourself 'doctor', 'Mr' or whatever kind of licensed healer you were? Well, until the middle of the Century, you had a number even of ecclesiastical licenses - I mentioned these before - the Archdeacon's Courts, for instance, could allow an educated gentleman to practise medicine in his parish or part of a dioceses if there was no doctor living around.

But let us say you are talking about proper London-based medicine. The defining feature of 19th Century medicine comes to be the Apothecaries Act of 1815. Apothecaries were not doctors. By this stage they were not only the mixers and the preparers of drugs; they came to be rather like GPs. You could go to an apothecary - he was not legally permitted to consult with you in your house, but you could go into his shop, describe your symptoms, and then get something over the counter. The Act of 1815 regularised this practice. It said that the apothecaries' apprentices - notice they were called 'apprentices' not 'students' - his apprentices required to undergo a full five-year training and then, before he could offer himself for examination, usually to become a Licentiate of the College of Surgeons, he had to have walked the wards of a recognised public hospital for at least six months. This of course would normally have been one of the big London hospitals, but later on in the century, it could have meant one in Liverpool, or Newcastle, or somewhere like that, but at least it now meant that you had to be plugged in to the academic medical world.

By the 1840s, apothecaries' apprentices were required to do more and more things to qualify and obtain certificates for having attended courses in chemistry, physiology, the dissection of human bodies, and things of this sort. What you find is that the Apothecaries Act of 1815 creates that enduring feature of healthcare - the General Practitioner. Most people therefore who are practising medicine by the middle of the 19th Century, who are family doctors or 'gone into family practice' as it was said, had normally come up through the Apothecaries Act, and even after it started to become more common, after the founding of UCL and King's, to spend more time in a hospital than in an apothecary's shop, you would still normally take your licensing qualifications through the apothecary system.

So this becomes the bedrock of the system. It is of course perfectly workable within the medicine of the day - diagnosing, prescribing, knowing the nature of diseases, and working within the general skills system, where you might occasionally bleed, leech, vomit, and so on. In the Museum of the History of Science in Oxford, there are medical instruments from the early decades of the 19th Century that were still used for propping, leeching, vomiting, bleeding, and so on, and so these procedures would still have been under the Apothecaries Act.

But then, in addition to those who went to more formal institutions and acquired the at least courtesy title of 'doctor', you will then start to find the proliferation of bodies catering for their broadly intellectual needs. London, for instance, starts to see the proliferation of local medical societies. In 1805, they clubbed together and formed the London Medical and Chirurgical Society - the London Medical and Surgical Society.

They then do something very significant: they start to issue a journal. Another major feature of 19th Century medicine is the literature it generated - literature on cases of all kinds. If you were a doctor and you had a case, then you would report it to whichever journal. The literature of the Medical and Chirurgical Society runs for many years, and I have had two or three students in Oxford who have worked on that journal for the first fifty or sixty years that it was going. You also tend to find as well that you have a Letters to the Editor Page with people attacking each other in that publication. Also, by the 1860s, with the emergence of the German chemical laboratories, you find what you might call the 'drug of the year' being advertised - 'this is a sovereign cure for' this, that, and the other, of course usually fading away, because, although it may provoke some symptoms in the patient, it normally produced traumatic side effects as well. But you begin to get this process of advertising medicine in these journals.

Then you have another journal, which I am glad to say I own a run of several copies - Braithwaite's Medical Retrospect. Braithwaite's Medical Retrospect was published annually, and it contained papers on any branch of medicine. It was run by a private publisher, edited by a man called Dr Braithwaite, and when he died, the title carried on with another editor. It became another of these particularly provincial journals, with a lot of material from the Leeds/Manchester area in Braithwaite's Medical Retrospect, dealing with cholera, typhus, how to handle an epidemic, this kind of material. But you now have medical practitioners with this literature in circulation around the country, especially after the advert of the railways where, quite simply, a journal could be published in London on Monday night, and it could be on sale in Newcastle on Tuesday morning.

But of course the most famous of all medical journals comes from this period - the Lancet. This is now, of course, the journal which is the very paradigm of medical respectability, but we have to bear in mind that that is not how it started its career. It was started in 1823 by a young Devonshire surgeon who had trained in London and basically felt miffed by Astley Cooper and the Guy's and St Thomas surgical elite. They had not given him the preferment he felt he deserved - he had been promoted over - and he went into medical journalism. You may wonder why is it called The Lancet, and the answer is that it was intended to dissect the profession, quite simply. In the early days it was a sort of medical Private Eye of its day. He had a number of favourite victims, and one of the favourite victims of course was Mr Bransby Cooper, who was Sir Astley's not terribly gifted nephew.

Now, let me fill you in about how the promotion system within London medicine was working in the 1820s. Astley Cooper married and had no children - actually, he had a daughter who died, but he had no sons. He was very keen to form a medical dynasty. He was driven more or less in extremis to take on his nephew, Bransby, who is a proven incompetent at everything that he had done. He then has Bransby sent to Edinburgh, where he acquires a general medical qualification and an Edinburgh MD. He is then articled to his uncle at St Thomas's and goes through the surgical system. As a young man, he is sent away to Spain, to serve under Wellington in the Peninsular War, where Thomas Wakeley, in one of his very sharp, quippish little remarks mentioned that 'Mr Bransby Cooper was sent to the Peninsular to add his own personal horrors to that campaign.' On that occasion, Bransby Cooper amputated a wrong leg! That appeared in The Lancet.

This idea therefore of medical journals and the appearance of these journals was not just to spread medical knowledge, and a journal which of course, by 1870, had become a model of medical respectability, starts its days as something of a scandal rag within the profession. This is part of the sheer growth of the amount of medicine. You do not start producing these journals if there are not people able to read them, and of course contribute to them.

As I have mentioned, you began to see the emergence of definite medical training. The 19th Century therefore invents - and this is again a barometer of the profession - the character 'the medical student'. Now of course, Harvey had been a medical student, Hunter had been a medical student, but the medical student who was idle, drunken, stole things in streets, caused noises at nights, kept the neighbours awake - he is a Victorian invention. Of course I am not saying they did not do it before, but he becomes a recognisable character by the 1860s. In fact, Dickens not only has several medical students in his novels, but there is one particular figure I want to mention to you.

You may never have heard of this one, because the book from which it comes is basically quite scarce. I do not know the author's real name; his pen name was Aesculapius Scalpel, which of course tells you quite a lot about the novel, and the novel is called St Bernard's. It was published in 1887, and from the figures, dates, characters mentioned in it, I would say was probably intended to be St Bartholomew's in the early 1860s. In the book, he tells us a great deal about the japes of the students. He has, for instance, one friend who had 57 brass door knockers that he had stolen from people's doors in the dead of night, and this man was proud of the fact that he could steal door knockers without arousing the people inside the house. We are also told about the way in which you dissect, the stench in the dissecting rooms, and that it was common for students to all smoke cigars whilst they were working. So we find an enormous amount of detail of the inner character of what it was like to be a student in this period. The thing is though, you are now talking of a recognisable character - the medical student - by the 1860s.

Also, professionalisation does something else: it creates a new branch of the profession, and this is the professional nurse. Of course, we all know about Florence Nightingale, and we all know of the whole business to create a new nursing class, with women from a different educational and social backgrounds. We have this very bad image of the nurse before Florence Nightingale or Josephine Butler or the reformers of the middle of the century. On the other hand again, St Bernard's, the novel, has some fascinating insights about nurses. There is no mention of Florence Nightingale - this is pre the Nightingale movement, and of course she starts in a large way to found her own nursing school at King's College Hospital in 1860, Bart's founds its nursing school in 1877. But in fact, in this novel, there is a woman referred to as Jane Podger. Clearly Jane Podger may have been an assemblage of various real nurses whom he had known as a student, but we are told that Jane Podger was fond of gin; she was certainly keen for a tipple whenever one was going, and she also smoked occasionally, but we are told that she was the person in charge of St Bernard's Admissions Ward, what we would now call the A&E Department. It was said that she could straighten any limb, ligature any cut, dress, treat, bandage any accident perfectly; the thing is she was never allowed to do it legally, because she was only a nurse. Therefore, we are told that she was a superb teacher, because what would happen, if you have, for instance, a railway worker brought in with a badly smashed leg or someone like that, they would ring the bell, and of course you would not have a doctor coming in to the A&E, you would have a couple of students lounging around outside. Of course, if you are a second year student and you find a man with his leg hanging off, or a bad break of something of this sort, then you would not know what to do. In fact, we were told that Jane Podger would tell them exactly what to do, and that she was the best teacher in the hospital. Of course, it is true that she was a fictitious character, but clearly, whoever Aesculapius Scalpel was had met nurses like that. Yes, she had her downside - she was fond of a tipple and even a bribe occasionally - but she knew what she was doing. So one has to ask the question of people like Florence Nightingale and Josephine Butler, with their new movement for improving the status of nursing, whether perhaps they were drawing too wide a gulf between what they were trying to achieve and what was there already.

These, then, are some of the professionalisms which are emerging in the 19th Century. On the other hand of course, I called this lecture 'A City Well-Scrubbed', and one of the dominant themes of 19th Century London, as it was of any big city, was the fact that it was appallingly filthy. Now why was this? Why had there been this colossal escalation of population and why was disease so rife amongst it?

Demographers and historians still argue why there had been this colossal increase in population. One suggestion has been that inoculation and vaccination against smallpox, especially amongst children, now meant that people who would have died early lived to reproduce, so you start to have an exponential growth of the number of people.

Also, industrialisation tended to mean that more and more people left the land as a source of work and gravitated towards the big cities. London of course, what William Cobbett calls the Great Wren, the Great Cancer, sucked in this vast number of people - people working on the docks, building, railway projects, and things of this sort. So you have this vast body of the poor, many of them living not far from the river.

The great problem, if you lived near the river, was that the Thames was both sewer and water supply. This was brought dramatically and terrifyingly home in October 1831, when London found its first onslaught of Asiatic cholera. This initially killed 6.000 people, you may say not an enormous number in a population of maybe 1.25 million, but it nonetheless caused outrage as to why this had happened. Nobody at this stage knew what had caused the disease.

On the other hand, there were those who were coming to suggest that dirt and lack of water supply had something to do with it. Now, we have to bear in mind that germs are thirty odd years in the future. Germs are creatures of the 1860s, not of the 1830s. I would suggest that the idea of the great clean-up of London, which takes place between the mid-1830s and effectively the mid-1870s was largely done on almost what you might call a wing and a prayer. Nobody quite knew why dirt was bad for you, nobody quite knew why clean water was better than dirty, but we therefore invested millions of pounds in great projects of civil engineering, somehow or other to juggle these two things around. I think it would be impossible today to fund such projects. If you now went to any kind of funding body and said, 'We need to totally transform the entire geography of this city - we do not quite know why, but it will cost so-many billions of pounds,' I cannot imagine very much lottery money, let alone anything else, entering that fund. But this is what happens in the 19th Century.

One central driving feature of this is Edwin Chadwick. He was not a doctor; he was one of the first Poor Law Commissioners, and he was concerned with the problem not only of sickness and disease, but escalating poverty, especially in the metropolis. What did you do with those who were out of work, indigent, or whatever? Basically speaking, of course one of the key things he does is one of the driving forces behind the Poor Law Amendment Act of 1834.

You may ask what it is amending. In response, it is amending the great Elizabethan Poor Law of 1603, and that law, which was intended for a population of four million, rather than a population of ten million, is now utterly incapable of delivering. It worked on the idea that the poor should be dealt with on a parish level, and the local ratepayers should contribute what was called Outdoor Relief. In other words, if you were poor, and it cost let us say eight shillings a week to live minimally in your community, then you would be paid eight shillings a week from the parish. But this was no longer working: there were simply far too many people, and many parishes had so many beggars and poor people living in them that there was simply not a rateable value enough to pay.

This invents that concept which of course Charles Dickens lambastes severely - the workhouse - the idea that you had the principle called 'least eligibility'. Before you can receive a penny of public money because of your distress, you have to be least eligible for all forms of other support: (a) you cannot get a job; (b) you will be separated from your spouse and your family; you will be made to do work inside the workhouse; and in addition to all of this as well, you will be living under an iron regime. The intention was to discourage you in every possible way from entering a workhouse and claiming public money.

Though the one thing about the workhouses, where they did have some value, was that they normally contained sick wards. This therefore tended to mean that some kind of at least primitive therapy was often available, and very often, men who had qualified under the Apothecaries Act were sometimes given appointments in these places. There is, for instance, a Punch cartoon from 1848, which shows a panel of rather fat parish officers about to appoint a new hospital doctor for their workhouse, and this young man is himself in rags, he has just qualified, and they are haggling as to whether they will pay him 18 and 6, or twenty shillings a week as a workhouse doctor. So of course the therapy was not of the most sophisticated order in these places, but there was a recognition that there had to be something provided.

What one starts to find here too is the realisation that if somehow dirt causes disease, how can you remove it? Especially after 1848, this led to a new body of health legislation, the first ever National Health legislation passed in this country - the Public Health Act of 1848. This was brought upon by the second great cholera epidemic, which was three times more terrifying than that of 1832 and caused serious concerns. Again it was pointed out that the poorest were hit the hardest and it had something to do with drinking water. It is at this time that Charles Kingsley, 1849, comments about the dead cats around the river, where of course people are drawing their drinking water in Southwark. So, in consequence therefore, questions are coming to be asked about whether you can legislate against poverty and dirt. The question is of course what are you actually legislating against? What is bad or good against cleanliness and dirtiness? Here again is where, like I say, this whole approach works on a wing and a prayer, because nobody quite knows what is actually working.

Then there was the Great Stink of 1859 when the Thames literally was so bad that Parliament had to adjourn. This led to the undertaking of the colossal rebuilding of the London sewage system. This meant that vast trunk sewers on the north and south sides of the Thames were created and the present day Embankments were created from the toppings of these things. Of course Sir Joseph Bazalgette of really was the creator of this scheme, and of course, within twelve years - this is the astonishing period - we are dealing here with hundreds of miles of sewers and the trunk sewers as big as this room - but at last, by the mid-1870s, London was cleaning up.

There was also legislation for the water companies, and I think here perhaps a salutary lesson to the privatisation of public health today. Places like the Chelsea Company, for instance, which supplied a lot of the water for Westminster and North side of the river, was in fact shown by Michael Faraday to contain all sorts of nasty things floating around inside it, and this was even supplying the West End. So in consequence, should you, like the Romans, bring in your water from great distances and make sure it was pure, or could 19th Century science, by floating it through sand and through various other places and using steam engines to pump in, really make sure that you could take water even from old father Thames himself, treat it, and serve it pure, wherever you were living in London? This of course is practical medicine, but its product does not come from doctors - it comes from chemists and from civil engineers, and it shows the way how health is not just a problem for doctors by the 19thCentury.

On the other hand, when you look at the medical community in the 19thCentury, and not just London but across Britain, you may wonder what has happened to the quack, the characters we saw last week - have they died out? After all, medicine is getting better. I have done quite a lot of work on popular medicine of the 19th Century and the way in which ordinary people, on the whole, either people who were only just or not even functionally literate, perceived disease. I have never ceased to be fascinated by the fact that as scientific medicine grew in the 19th Century, quackery grew in tandem. What I think the difference is though is they now start to socially diverge. The people who are increasingly using quack remedies are those who are least well off and those who are most estranged from mainstream society. But how do you get at what ordinary people thought about medicine, for instance, in 1860?

One fascinating source that I have found are advertisements for quack medicines. We are lucky here because the Wellcome Institute for the History of Medicine here in London have one of the biggest collections of advertisements for quack medicines that survives, and I also have collected a good number of them myself. Of these medicines, they never told you what they contained. They were all secret, and they always came from a long way away - they had come from India, or the Red Indians of South America, or the Chinese. They were always secret and wonderful, and they all came from cultures where apparently everybody lived to 150 years old! What was important was that it told you want it would do for you, and when you read many of these claims, you begin to wonder whether this mid-Victorian or medieval Britain! For instance, you will find such promises as: 'It will cleanse heavy humours', 'It will purge pile', or 'It will lift your animal spirits'. - This is Tudor medieval stuff!

I have come to be fascinated by how ordinary people still inherited this culture, and I have found a lot of connections for where it came from. Not only of course do you have a number of Elizabethan writers writing things like what they called poor men's physic - people like Andrew Board and so on, who write these very simple little booklets; but you then get figures in the 18th Century writing them as well. There was one immensely influential little book, still at a time of course when medicine can do relatively little for you, and this was by John Wesley. We often forget that John Wesley was fascinated by practical medicine. In 1747, he wrote a little booklet called Primitive Physic: Simple Medicine. It was intended to be simple home cures for ordinary folk. The Bodleian Library catalogue lists over seventy separate printings of Primitive Physic, running into the mid-Victorian period, and when you consider the immense impact of Methodism in the 19th Century, in England, Australia, the United States and so on, you can understand how these ideas spread. Wesley's own approach to medicine was very conservative and very simple, and I often wonder how far Primitive Physic, as it were, created this popular culture of medicine.

But you also get a number of other features drawn in as well, characters which you really have to wonder where they heck have they come from?! - The Learned Galen, the Great Aesculapius, the Wise Hippocrates. If you are living in a slum in 1860 and you are practising medicine thinking in terms of medical concepts that perhaps come from the Greek Hellenic world, then there has been an extraordinary process of cultural transparence. I have this directly from personal experience because my own interest in the history of medicine started as a boy. I come from Manchester and my Grandmother, who was born in 1891, had grown up in the mills and came from exactly this readership. I remember Granny talking to her sister and to their friends in the late 1950s about things like 'thick humours' and one chap I could never quite understand - 'Harry Stotle'! How on earth did this culture penetrate, and how to unravel that culture was what really led me into trying to understand where so much popular medicine comes from.

In terms of 'Harry Stotle', one major work that he produced was Aristotle's Works, a compilation I traced back to the middle of the 17thCentury, and it contains basically a ragbag of therapies, a lot of them broadly concerned with what they generally called in those days 'women's complaints' - pregnancy, childbirth, things of this sort - and Aristotle's Works became a thing that survived well into the 20th Century - I own a 1907 printed edition of Aristotle's Works. Indeed, Peter Warren, who used to be the Radcliff Science Librarian in Oxford, said that when he was growing up as a lad in Bristol in the 1940s, there was a local shop where, if you could sneak behind the counter, you could see these books there, ready for sale to the public in the 1940s.

So when you talk of a quack tradition, one is not just talking of some vague thing; you are talking of an astonishing persistence of literally a medical counter-culture which is moving amongst the illiterate, the sub-literate, the poorly educated, traditionally, well into the 20th Century. I am fascinated in how medicine bifurcates, as it were; how it splits into an academic scientific tradition, and still retains this populist tradition as well.

Having said that about quackery and what you might call early alternative practice, I want now to get onto the business of what I mean by a critical mass of medicine. What actually was happening in the 19th Century to make medicine eventually work, so that what you did in the dissecting theatre or in the laboratory could have some genuine, practical application in the hospital ward? These are a number of things, which I think were crucial to this development.

One of these was the rapid escalation of physiology in the first half of the 19th Century. In particular, where you start to think not just of anatomy which is about the body in a static condition, but also about physiology which is about the body in coordinated motion: how the blood, the nerves, the bio-duct, how these things work together. This starts by systematic experimentation on animals. It had started with people like Gresham College's own Robert Hooke in the 17th Century, but nonetheless, it is being done on what you might call an industrial basis by the 1840s. Magendie in Paris becomes the greatest experimental physiologist of the age. Many Englishmen, having done their initial stints at UCL or somewhere like that, would go off to do a couple of years with Magendie in Paris. There, they would operate on cats and dogs and monkeys and rats and all sorts of things, and acquire a knowledge of how living bodies operate. This, I think, adds to this critical mass.

Along with pathology, you find the growth of the study of what actually is the death process - what is pathology, what is aging, what happens to the body when it goes from its perfect, fit, theoretical condition to the condition where it develops severe symptoms or dies? This also starts as a rigorous scientific discipline in the 19th Century. People like Charles Bell at Edinburgh; and then the study of the nervous system with people like Hughlings Jackson; and of course the nervous system's connection to the brain, in Oxford and in London, with Sir Charles Sherrington, by the end of the 19th Century. Physiology and pathology therefore start to add vast things as to how we understand the disease process works.

But then I think it is impossible to underestimate one single contribution, and this is chemistry. It is true that doctors have studied chemistry from as long as we know. We are told that, for instance, Galen himself was fascinated by the behaviour of substances in the oven, and of course Paracelsus, in the early 16th Century, talks about medicine as a chemical business. But basically, this is moonshine, because you had no real idea what a thing is doing to you, so you have the concept of chemistry and medicine, but still a therapeutic blank wall. The 19th Century changes that. I think where this particular source comes from, as in fact as we were speaking having tea beforehand, is largely out of early 19th Century Germany.

When it was reconstructing its intellectual culture after the ravages of the Napoleonic wars, Germany began to develop chemistry as a mainstream discipline. Chemistry, we have to bear in mind, has undergone colossal change in the preceding forty or fifty years. If you go back, let us say, to Priestley's time, in the 1770s, you have the concept of elements, electrolysis, Davy, the young Faraday. But by 1820, you know that the world is made of what they then thought were about forty elements, some of them gases, some of them solids. They blended in particular proportions and formed all substances, and you could split them apart and reassemble them using sophisticated laboratory techniques. But all of this is only useful for physical chemistry, those things which actually are concerned with salts and acids and so on. The question is do living things have a special chemistry?

Then, in about 1820, Wohler in Germany synthesised the first organic substance from non-organic materials. He synthesised urea, therefore suggesting that living chemistry - organic chemistry as it would later become - has a similar structural, albeit more complex, basis to that of acids and salts.

Then, Justus von Liebig, first of all at Darmstadt and Giessen, basically becomes the great prophet of organic chemistry. Getting the Chair of Chemistry when he was only 23 and carrying on to the 1860s, when he was in his sixties, Liebig really creates organic chemistry.

In 1842, he published a colossally influential book in German which was instantly translated into English: Animal Chemistry - basically the chemistry of living things. I currently have a research student in Oxford, Cecily Burrell, who is working on it, so I give her a few acknowledgements for information that she has told me straight out of that. What you find in Animal Chemistry is the realisation that the things that are in living bodies are shared in common, and we share them with animals. Things like proteins; the fact that blood, for instance, seemed to show similar characteristics under the microscope whether it is the blood of a horse or the blood of a human being, although it is true they often had different key features, microscopically. What chemistry does therefore is create a whole new series of understandings, how living things work on what you might call an invisible level.

But also chemistry is expanding so much in the 19th Century and we are beginning to unlock the way in which substances are made. You can also do things such as something which had been the dream of doctors back to Greek antiquity: you can have utterly pure drugs. If you take some plant juice or some plant extract - let us say like an opiate - and you are not quite sure what it will do to - whether it will just pop you out for the night, or whether it will kill you. On the other hand, if, as in 1806, the Swiss Sertumer extracted pure morphine from crude opium juice, you have now got an exact clinically active substance. Exactly the same for quinine, for cocaine, and for many other drugs by the 1870s. Moreover, you do not merely have these drugs; you have new methods of delivery. Charles Woods' invention of the hypodermic syringe in 1855 now makes it possible to put an exact quantified chemical substance into the body and know that within seconds it will be affecting the brain of that person. In other words, medicine is now not only becoming much more exact in terms of its chemistry, it is also becoming much more exact in its mode of delivery within the body.

Also, this new chemistry makes possible new drugs that have extraordinary effects on people. We talk a great deal today of wonder drugs, a thing which transforms people's lives, and especially psychiatric drugs, but people rarely think that one of the most influential drugs ever invented in the 19th Century was chloral hydrate. Chloral hydrate was seen as a perfect sleeping draft. It was first marketed by German drug companies in 1871. Ships and railways and telegraphs and journals spread it around Europe within virtually no time, and of course into America. Opium or morphine will put you out, but in very unpredictable ways: first of all, you will be addicted if you need it for very long; then you will be constipated; and whilst you have got it, you will be having what Robert Hooke mentioned - wild, frightful dreams. But none of these problems feature for chloral hydrate, which gives sense to calling it truly a 'wonder drug'.

Now, how do you deal with the acutely mentally ill? One other class of institution developed in the 19th Century therapeutic world was the asylum. Of course, contrary to popular beliefs, the asylum policies in the 19th Century were amazingly humane, especially in places like Hanwell in Essex and St Luke's Hospital, the complement to St Bartholomew's, here in London. But what should you do with people who were perhaps violent or at least very disturbed? You could not sleep them; you could not give them opiates - you would make them worse. Chloral hydrate was the wonder drug. Chloral hydrate gave you eight hours' sleep. It metabolised roughly at the same rate as the period of time you were asleep. You woke up with minimal side effects, and you did not have wild, frightful dreams. Chloral hydrate transformed the management of the acutely mentally ill in the 19th Century, and again, it is one of the first drugs to actually have this impact.

I may also say too that it killed one of Victorian England's most famous physicists. The great Irish physicist, William Tindal, was a lifelong insomniac and his wife used to give him chloral hydrate. Woken up in the middle of the night by him in 1888, when he could not sleep, she staggeringly mixed his medicines at the bedside, gave it him to drink, and suddenly realised she had given him 90% chloral hydrate, 10% water, and he never opened his eyes again. Of course, this is one of the dangers of sleeping drafts - of course the mix should have been the other way around.

So chemistry does all of these things.

Another absolutely central feature in 1858 was Rudolph Virchow, the discoverer of the nature of the cell. Again, Gresham College's own Robert Hooke first described cells in cork and wood in 1665. They had no concept really as to the nature of their function, but it was Virchow, in Germany, who realised by 1858, by a series of fifteen years' research, that cells are the nature of all growth processes in the body. In fact, he even invents a Latin tag that goes over Aristotle. Aristotle's famous dictum 'all things comes from eggs' was changed to 'cells make cells make cells make cells.' The idea that healthy and diseased human growth is a product of cells is absolutely central, and after 1858, this new approach was central to how you treat a person and especially how you diagnose using cellular analysis. It was also Virchow who first identified leukaemia, and he does this through microscopic examinations of the blood and of course, as a well-trained classicist, as he was, calls it white blood.

But then how would you do all of this but for a revolution in optics? The medical microscope is also fundamental to this culture. London forms, first of all, The Microscopical Society of London, in the 1840s. It later becomes, as it still is, the Royal Microscopical Society, and my own friend and former supervisor, Professor Gerard Turner, who introduced me on the first of my Gresham lectures, had the honour of being one of its Presidents. The idea that microscopy was becoming in itself a discipline, and new and increasingly sophisticated microscopes were being employed to study all kinds of structures in the natural world, including of course in the human body, also adds to this vast diagnostic process.

Very centrally too is when the microscope, by the 1860s, comes to be teamed up with the wet plate camera, and you start to take photo-micrographs, which you can then, just like a slide on a screen, blow up and see in immense detail. This makes possible the other great 19thCentury critical mass contribution - bacterialology. It suddenly now becomes possible to see things on an extremely minute level, and as Robert Kock in Germany in 1872 realised, you could not only see them, but photograph them. The thing is though, what are you seeing and photographing? If you have someone with cholera or diphtheria or any other disease, and they spit or whatever on a microscope slide and you stick that under a microscope, you will see all sorts of little things wriggling around inside it. How do you know what is what? This of course becomes the great process of recognition.

But I would just like to precede that by a second. The first realisation that diseases were not miasmic - in other words, were not blown on the wind, as Galen and Hypocrites had suggested that they were - the first realisation that there was contagion, person to person infection, was made by a Bristol surgeon, who had qualified and trained in London, Dr William Budd. In 1839, William Budd was a GP at the very beginning of his practice. He was a GP at the parish of North Taunton in Devon. He describes the parish as 'a traditionally filthy country parish.' Of course, now the idea of lovely little cottage and chocolate box houses and so on is more appropriate, but in fact it was a filthy hovel, basically speaking. Typhus was not known then, and then it suddenly broke out. His first case was on 11th June 1839 - eighty people suffered from it and half of them died. Four people left the village, and each of the contacts with which those people had made connection went down with it as well. This leads Budd to study the transmission mechanism. He knows nothing of germs, but clearly this disease is a person-to-person connector.

He does a similar thing a few years later with phthisis, pulmonary consumption, when he publishes a paper in London, which gets a great deal of shouting at because it contradicts the miasmic theory. A particular incidence he had been told of was a ship that had visited the Gilbert Islands in the Pacific, and there had been a sick sailor and the captain had left the man onshore to recuperate for some time. The natives on the island were completely friendly and promised to look after the man. The captain returned about a year later, to find the man recovered, and most of the islanders dead of phthisis. He was of course a consumptive. Now, this, Budd argues, is a clear indication that phthisis is not an hereditary disease; phthisis is a contagion - person-to-person - because these peoples on the Gilbert Islands did not know the disease and yet it just sailed through them.

This is a crucial approach to bacterialology, and what you start to find is, with Pasteur's crucial work on fermentation in 1871, a Professor of Medicine at Breslau in Germany, used his microscope and Pasteur's discoveries, to come to the conclusion that there is one thing that all the people he has examined who have diphtheria have in common, and that was a particular microbe. It was the first ever recognition of a specific microbe to specific disease - 1871, with diphtheria.

Louis Pasteur is not a doctor but an industrial chemist and an extremely astute one, and he came from this chemical direction into medicine. His paper is studied by Joseph Lister. Joseph Lister, by this time, of course he is a London graduate, he has become Regis Professor of Surgery at Glasgow, gone on to Edinburgh, and was struck by the appalling mortalities in surgery, even after anaesthesia. Now anaesthesia had first been introduced in London, from America, on 21st December 1846, at University College Hospital, where Robert Liston was the operating surgeon. Now, the younger Lister starts to use the techniques of anaesthesia right from the word go, so he never operates on conscious patients. He recognises, as surgical techniques become more complex, when you spend a bit more time on an operation, when you do not have your dresser with a stop watch to get the leg off in the minimal time, you might spend twenty minutes on doing a really good job - and the patient is completely out. But why do they die of sepsis?

What he picked up from Pasteur's paper was the realisation that there could be something in the air, which could somehow have entered and caused an infection. This leads him to invent the carbolic spray - a thing which he later regretted because he realised it was rather like using a shotgun to kill a fly. But the realisation that if there could be microbic forms in the air, and that sepsis was not spontaneously generated in the wound itself, led one to the question of whether one therefore invent safe surgical techniques? Lister goes on to develop a series of procedures, using lints and gauzes, but he realised very centrally, of supreme importance, was clean hands and clean instruments. Once he made this discovery, he suddenly finds when he starts to publish his results that his surgical infection cases have dropped from 45% to 2%.

He becomes Professor of Surgery at Kings College Hospital, and of course finds in England there is an extraordinary resistance, especially in London, to the new techniques of antisepsis, and I think this has something to do with the very character of English science at this time. People could not accept Lister's early work because, at this stage, you could not demonstrate 'this particular vaculus causes this particular infection'. Yes, you might have a general scrub, you might have a general clean, you might use carbolic strategically, but you could not prove by scientific connection exactly why an infection is taking place. It is not for nothing, rather ironically, that he was first hailed as a medical saviour in Germany and then in America before he was recognised in England, but once the Listerian technique has developed - and it is pretty well established by the 1880s - it is then perfected.

The Mayo Brothers, working in Minnesota in the United States, then take it one stage further: they ask: why necessarily deluge everything in carbolic? If we then have a perfectly clean patient, a perfectly scrubbed surgeon, wearing a gown, then you will not infect them in the first place, and you do not have all the irritants that take place when you are spraying acid all over the place. Very rapidly, Lister's techniques have been supervened by 1890, to a new aseptic, not antiseptic, surgery.

By 1900, the speed with which virtually all the branches of healing have developed have been colossal. Like I say, not many of them had been there in 1830, when Astley Cooper was teaching Bransby how to amputate legs in St Thomas's, but within that seventy year period, medicine had simply transformed beyond recognition, and whilst they did not quite understand how this had happened at first, it was realised for a long time it was concerned with being in a place that was well scrubbed.

So, I have now taken you through three centuries of how medicine in London occurred. Of course a lot of what I have said tonight did not apply just to London, because by the 19th Century, medicine is an international culture, and what was being done in Germany was being replicated in London, New York, and so on. But, of course, why London becomes so important in this is because it becomes the crucible of so much of this medical innovation.